NEW YORK — As World AIDS Day approached, the United Nations admitted it had overestimated the number of persons infected with HIV. Might it also correct its perception about condoms?

by Sue Ellin Browder | Source:

The Joint United Nations Program on HIV/AIDS (UNAIDS) sponsors World AIDS Day, Dec. 1, and this year its slogan is “Stop AIDS, Keep the Promise.”

In a recent interview with Reuters, Alberto Stella, coordinator for the UNAIDS program in Nicaragua, Honduras and Costa Rica, blamed the Church’s objection to condom use for spreading AIDS in Latin America.

“In Latin America, the use of condoms has been demonized, but if they were used in every relation, I guarantee the epidemic would be resolved in the region,” Stella said.

But it’s the Church that’s being demonized, an African AIDS activist said, because condoms “have never reduced HIV/AIDS rates anywhere.”

Edward Green, director of the AIDS Prevention Research Project at the Harvard Center for Population and Development Studies, said, “Passionate debates like this typically erupt when people fail to understand there are two different kinds of HIV/AIDS epidemics.”

Surprisingly, epidemics in the Latin American countries Stella oversees are fundamentally different from epidemics in sub-Saharan Africa, where Ssempa lives and works.

Epidemics in sub-Saharan Africa, on the other hand, are generalized epidemics, meaning most infections are in the general population, not in high-risk groups. Sub-Saharan Africa bears the brunt of the global AIDS burden. Two-thirds of the world’s AIDS sufferers live there. It’s this type of population-wide epidemic that destroys families, kills millions of people and leaves behind millions of orphans.

“A ‘debate’ between Ssempa (who is basically correct for Africa) and Stella (who is talking about Latin America) is a non-starter and can only create confusion,” said Norman Hearst, a family physician and epidemiologist at University of California, San Francisco.

It’s easy to grasp how HIV epidemics erupt within high-risk groups like needle-using drug addicts, homosexual men and prostitutes. But what causes and drives population-wide epidemics like those in Africa?

“The latest research now proves it [derives from] sexual networks of people having two or more regular sex partners,” Green said.

The HIV virus can be passed in the blood supply, via needles shared by drug users, and from pregnant or breastfeeding mothers to their babies. But the driving cause of population-wide epidemics, Green reiterates, is “people having sex regularly with multiple partners.”

As for Stella’s claim that if condoms were used in “every relation” in Latin America the HIV epidemic there would end, first it’s unnecessary for everybody to use condoms because the epidemic isn’t in the general population. Second, “It’s a meaningless statement. He’s living in a fantasy world, because it’s never going to happen,” Green said.

Despite repeated attempts, the Register was unable to speak with Stella.

Prostitutes may use condoms in 90% or more of paid sex acts if they’re required to by law, as they were in Thailand and Cambodia. If they do, HIV rates in brothels (where laws can be enforced if great efforts are made) may then drop. But among heterosexual couples in generalized epidemics, “consistent condom use occurs at most in only about 5% of the population,” Green said.

In one much-publicized study in the Rakai district of Uganda, people who said they always used condoms reduced their HIV risk by 66%. “But in Rakai, only 4% of the population used condoms consistently,” Hearst said.

“What’s more,” he added, “people who use condoms just some of the time don’t cut their risk of HIV infection at all.”

“Even some condom promoters know there’s very little demand for them,” said Green, who once worked for the second largest condom marketer in the world.

“Many people who consider themselves AIDS ‘experts’ believe condoms are the only answer. But, in fact, condom promotion has not worked in population-wide epidemics as a public-health strategy,” Hearst said.

Some AIDS activists believe that if condoms were only promoted more aggressively, people would use them and HIV rates would fall. But, contrary to these expectations, in HIV epidemics like those in sub-Saharan Africa — where 72% of global AIDS deaths occur — condom promotions may actually raise HIV rates.

In his groundbreaking book Rethinking AIDS Prevention: Learning from Successes in Developing Countries, Green points out that as the average number of condoms per male ages 15 to 49 in African countries rose between 1989 and 2000, HIV prevalence also skyrocketed. South Africa, Botswana and Zimbabwe, which had the world’s highest levels of condom availability per man, also had among the world’s very highest HIV rates (20% to 36%).

When UNAIDS asked Hearst to do a scientific review to see if condom promotions had reversed HIV/AIDS epidemics, he too concluded the promotions had not simply failed: They’d backfired. To his surprise, Hearst found that countries with the most condoms per man tended to have the highest HIV rates.

UNAIDS refused to publish Hearst’s findings.

At last, in March, 2004, Hearst got part of his review published in the journal Studies in Family Planning. The news was shocking. Between 1993 and 2001 in Botswana, as condom sales rose from 1 million to 3 million, HIV prevalence among urban pregnant women shot up from 27% to 45%. During the same period in Cameroon, as condom sales increased from 6 million to 15 million, HIV prevalence rose from 3% to 9%.

“There are loads of things in medicine that look as if they ought to work. But ought to work and do work are two different things,” Hearst said.

Enoch Numan, 29, a teacher who lives near Kampala, has witnessed the tragedy that results when condoms fail. One of his older brothers is married but has had many girlfriends.

“He had a dresser drawer full of condoms. He always said, ‘Don’t worry about me. I’m protecting myself,’” Numan recalled. Now the 37-year-old brother has AIDS — and he has passed the deadly illness on to his wife. They have two small children.

“Condom promotion in Africa has been a disaster,” Hearst said.

“What has worked in real life to stem epidemics in Africa is partner fidelity among older couples and sexual abstinence among young people,” Green declared.

In the late 1980s, before Western AIDS experts arrived to tell Africans they had it all wrong, Ugandans designed their own homegrown AIDS-prevention health message. It was called ABC (for Abstain, Be Faithful, or if you cannot or will not do either, use Condoms). The ABC message was everywhere: on billboards, in churches, in government offices, in schools. As a result, rates of 13- to 16-year-olds having sex in one district plunged from nearly 60% in 1994 to less than 5% in 2001. Fewer than 10% of unmarried Ugandan women reported multiple partners (compared with 20% to 65% of women in other African countries, such as Kenya and Malawi). Meanwhile, national HIV infection rates in Uganda dropped from 21% to 6%.

What’s more, Green argued, Uganda’s success was not due to condom use.

At global AIDS conferences, Green frequently tells the success story that occurred in the Karamoja area (two districts in the extreme northeast of Uganda). A 1997 study of people in Karamoja found: 74.5% had no formal education, 74% had never listened to a radio, 88.6% had never seen television.

Yet AIDS awareness was high because people talked about the disease with their families and friends. When asked, “Have you changed your sexual behavior due to AIDS? If so, how?” fewer than 1% said they used a condom. A whopping 91.9% said they were being faithful to one partner. As a result, Karamoja experienced a drop in HIV prevalence of at least 60%.

“As of this year, the HIV surveillance site for Karamoja found no cases of HIV infection,” Green said. “It’s the first site in Uganda to reach zero.”

Irene Mirembe, 24, who lives in Kampala, Uganda, and recently graduated from college with a degree in computer science, saw both her mother and father die of AIDS.

Seated on a couch, her hands folded quietly in her lap, she recalled, “All my life I knew my dad would one day die of AIDS. He wasn’t faithful. I told him to stop going out with other women. He never listened to me. He got the virus in 1995 and died in May, 2003.

“In the end, he could no longer toilet himself. You had to clean him up. You had to feed him. He was the only breadwinner. Every day we became poorer and poorer. If sex is not in a marriage, it has an impact on everyone in the family. Before my father died, we were tired of him. It has taken me a long time to forgive him.”

After her mother also died, Irene had sex with several men.

“I used condoms, but condoms didn’t protect my heart. Now I’m keeping myself for marriage. It’s definitely possible to live without sex,” she said, gently smiling. “Now there’s a freedom in my mind, a freedom in my heart.”

But now that Western experts and foreign donors have poured into Uganda to save the day, “the A & B messages are disappearing,” Hearst said, “and HIV rates are starting to tick back up.”

Sue Ellin Browder is based in Willits, California.Source: National Catholic Register - December 2-8, 2007 Issue

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